Talking Points: Catherine Kyobutungi on global health

I worked for three years as a Medical Officer at a remote rural hospital in Uganda after I graduating as a doctor from Makerere University. It was during this time that I realized I would better serve humanity by doing public health. The healthcare system was strained by the HIV/AIDS epidemic while dealing with the usual problems, and it felt pointless to operate in a system where death seemed inevitable and my role was to postpone it briefly. I felt that by doing public health I could do things that stopped people from falling sick in the first place.

From inception, APHRC has been a research institution that strives for evidence-driven policy impact. Our biggest challenge is not having enough resources to do sustained and consistent policy outreach and advocacy – most funding is for research but we need more funding for the outreach and advocacy that needs to happen when the results of new research and/or other evidence becomes available. In addition, the fact that we are an independent research institution, rather than a government-run organisation, makes it harder to forge and maintain long-term relationships with policy makers, especially those in government.

Kenya has a very vibrant research community, with excellent infrastructure and highly trained professionals. It is therefore very easy to find good staff in most areas and easy to find partners and collaborators. The presence of many international organizations also makes it an attractive place for non-Kenyans to relocate with their families, so we are able to attract staff from anywhere in the world. The connectivity by air and excellent conferencing facilities also make it easy to maintain partnerships with non-Kenyan institutions in different parts of the world.

APHRC is an African institution (which happens to be headquartered in Kenya), and so our impact model is continent-wide. The disadvantage of being based in Kenya is that it is not easy to achieve policy impact in other countries where we do not have a physical presence. Other than this, we face general challenges like most research institutions in the so-called Global South: unpredictable funding, exploitative and unequal partnerships, and a struggle to make our voices heard on matters that affect the continent.

There have been noticeable changes in the recent past but more needs to be done. Researchers in the Global South and their contributions to scientific publications are more acknowledged. But publications are only the end product of a research process that starts with research conceptualization. That’s where more needs to be done. It’s still common practice for researchers from Europe and North America to conceptualize studies, seek funding and then start looking for “partners” in Africa to conduct the research. By then, the roles and budgets of the African partners are already pre-determined, and in most cases, they are not aligned with the contributions, expertise and experience they would be able to bring.

In many instances, no budget is allocated for data analysis and scientific writing, and so the African researchers are mere data collectors. The more this kind of approach is used the further African researchers are left behind, while their counterparts in Europe and North America advance in their careers.

A bigger problem is the value of research to society, especially to the communities from which the data is collected. Because research is conceptualized without input from African researchers and other stakeholders, it ends up being of academic value only, without taking into account how the results could help shape policy and practice.

What I would like to see is a meaningful partnership grounded in the ultimate value of science to society. I would like studies to be designed with input from the African researchers, to consider the needs of the communities being studied, and to provide value beyond scientific publications. I would also like the tail end of the research process – that is data analysis, scientific writing, knowledge translation and research communication – to receive sufficient resources.

I have to say that living and working as a researcher in Kenya, I am constantly at the receiving end of the global health system that is still steeped in coloniality. I am affected by the dysfunction in the global health system whereby problems and their solutions are defined by ‘experts’, who don’t have any lived experiences and who have a poor understanding of the local context.

I am affected by the disproportionate attention paid to a small set of issues like HIV, TB and Malaria, at the expense of other health problems like non-communicable diseases. This disproportionate attention distorts the healthcare system, so that little attention is paid to the health problems that cause the greatest burden of disease and the policies and initiatives to address them.

As a researcher, it is much more difficult to make a case as to why certain areas are worth addressing, when the global health community is focused largely on the few pet issues that are deemed worth funding and investigating. This leads to a lot of duplication and inefficiency, while other critical aspects of the health system hardly get any attention. In addition, many of the solutions are driven by academic knowledge, which is inherently biased by the exclusion of the voices of people with lived experiences, whether they are local researchers and policy makers, or patients or study communities. As a result, many solutions do not work, or they require large amounts of (unsustainable) funding.

Global health studies, global health research and practice, make up what we know as global health. The three components are interconnected and influence each other greatly. What gets studied both influences and is influenced by what gets researched. What gets done (practice) is influenced by what the research findings reveal and is an opportunity to shape what is studied.

Therefore, to achieve better outcomes, we need to look at the totality of the global health system, not just one part. Among the many things that should be done to make global health more inclusive is a critical reflection about whose voices get to be heard and whose voices matter. How do we start listening more to communities, patients or frontline workers, instead of ‘experts’ who are far removed from the experiences of the people global health is designed to help? The global health community needs to make room for the voices of those we intend to serve, whether it is in research, in study, or the design and delivery of programs.

The reason why inequalities persist is because we pay lip service to equity. The sustainable development goals (SDG) framework and its various instruments have equity as a key feature. As a result, equity is prominent in global commitments and national health policy framework – but only on paper.

Most countries have not operationalized equity in their strategies or program design. The delivery and measurement systems are not set up to address inequity. It is much more common to measure the progress of countries or regions of the world towards various SDG targets, but rare to see equity analyses applied.

On the surface one may find that countries are making steady progress towards specific targets, while some regions within the same countries are being left further and further behind. When countries design specific programs, they rarely incorporate equity considerations in the decisions about resource allocation.

It is possible that countries would make faster progress if resources were allocated based on how sub-national units within the country are doing, so that the sub-national units or regions with the worst indicators, get the most resources. In short, for equitable health outcomes, we need to measure inequity continuously and incorporate equity considerations in the decision making.

COVID-19 was very disruptive to our work. Other than the terror and anxiety in the first few months, the lockdown meant that we were separated from family, friends and colleagues. We also could not implement most of our project activities, such as face-to-face data collection, meetings and training. It was incredibly difficult to balance staff needs, ensuring we kept everyone on the payroll without cutting any salaries, and keep the institution afloat financially. We had incredibly supportive partners and funders, and staff really worked hard under difficult circumstances. We finished the year 2020 still standing, with no staff laid off and in good financial health.

The lessons from the lockdown and disruptions were also channelled into new initiatives. For instance, we have now established a telephone database with thousands of phone numbers that we can use for future studies. We also established a virtual academy and converted our training materials into various formats suitable for blended learning. The systems set up for remote working have been retained, and staff are still working remotely. We are thus able to employ staff from different parts of the continent – they can effectively work from anywhere. This wasn’t something we had ever contemplated before COVID19.

A less apparent impact of the COVID19 pandemic was the recognition of the immense capacity that exists on the continent. African researchers and academics are often invisible to the world and their own governments. In the first year of the pandemic, countries had to rely on their ‘home-grown’ experts to generate evidence to inform their respective national responses. It was a proud moment for African scientists to showcase their expertise and get the recognition they deserve. Consequently, some countries dedicated financial resources to research – a trend I would also like to see in the future.

The erratic and unpredictable supply derailed well-laid national vaccinations plans, such that programs lost momentum. Even when vaccines later became available, the demand and interest had waned, and so countries were facing an uphill battle convincing people to be vaccinated.

As a result, Africa is still the least vaccinated continent in the world, with about 29% having received at least one dose, and only 21% fully vaccinated. The respective figures for the world are 68% and 62%. While other countries have given two, three boosters, in Africa the booster rate is in single digits. Some studies have revealed a high prevalence of antibodies against the virus, meaning that many Africans have been infected by the virus. Although this has not resulted in a high number of hospitalizations and deaths compared to other regions, we still don’t know what the impact will be in terms of the long-term complications of COVID19 and long-COVID.

I would tell them to go for it! There is a huge reward in a career like medicine, which directly touches people’s lives. The gratification from healing someone’s pain or saving a life of someone near death is indescribable. Having said that, Africa needs scientists, tens of thousands of scientists that can help in identifying the problems that cause ill health among the continent’s people, and lasting solutions to those problems. Africa needs thousands of science experts to speak for it at the many tables where decisions affecting the continent’s future are made. We will need the brightest minds from all corners of the world to deal with the myriad of challenges the world faces now. African scientist must be present and ready to play their part.

Catherine Kyobutungi was interviewed by Helga Groll, Associate Features Editor, eLife